To be considered for the scholarship, please fill out and submit the following information by January 15, 2012.

First Name: Last Name: Home Phone: Cell Phone: Street: City: State: Zip:	Email: Birthdate: High School*: City and State of HS: Intended Major at Cal: Cum. Unweighted HS GPA*: Cum. Weighted HS GPA*:
SAT or ACT test score and date taken:
Please list any college classes you have previously taken, and include the school, dates attended, and grade received. Also list the scores for any AP or IB exam you have taken:
Extracurricular Activities (from high school and college):
Please include any other information you think we should know when considering your application. We encourage you to use this space for any essay or personal statement you would like to submit, especially a copy of the one you sent to Cal:
How did you hear about this scholarship?

*If you are a transfer student use your previous college institution in the high school slot and use your college GPA for both weighted and unweighted GPA slots.